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/DEVELOPMENT OF A HEART FAILURE CLINIC DATABASE /
By

Pamela A. Ogden
/

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING
College of Nursing

1998

ABSTRACT
THE DEVELOPMENT OF A HEART FAILURE CLINIC DATABASE
By

Pamela A. Ogden

Heart failure is a devastating disease that has no cure. Patients diagnosed with
heart failure steadily decline and eventually die from complications of the disease.
Average life expectancy for heart failure is 5 years. Controlling heart failure and slowing
the progression can be achieved if patients know about their diagnosis and what they can
do to modify behaviors that would assist them in maintaining their health and
independence for as long as possible. Nursing can help patients with this process.

There was no database in place for use in the clinic that kept the patient
information needed and allowed for easy retrieval of those records. The purpose of this
scholarly project was to develop a computerized database that would efficiently maintain
patient records and track patient education for a Heart Failure Clinic. The database
provides an accurate and easy means to see trends in patient conditions, track what has
been done, and still needs to be done for each patient. The database is developed in

Microsoft Office using Word, Excel and Access to integrate the various components.

To Robert, Shawn, Rhonda, Jason, Brandon and Zachary Ogden

June Dufon and in memory of Frank Dufon

ACKNOWLEDGEMENTS

I would like to thank my project committee: George Allen, chair, for his guidance
and support; Kate Lein, committee member, for her support and time spent in reviewing
drafts of this project; and special thanks to Sharon King, my Advisor and committee
member, who gave me much encouragement, guidance, and friendship for this project and
while working toward my graduate degree.

Special thanks to my family. To my husband Bob, the wind beneath my wings, for
his unending love and support. To my children Jason, Shawn and Rhonda, and to my
grandchildren, Brandon and Zachary who have given me much joy and helped to keep me
grounded. Thanks also to my mother, June Dufon, for her words of encouragement and
her prayers, and in loving memory of my father, Frank Dufon whose spirit was with me

every step of the way.

1R;
1"

TABLE OF CONTENTS

LIST OF TABLES iv
LIST OF FIGURES V
INTRODUCTION I

Local Trends 3
Local Cardiovascular Health Status and the Need For a Heart Failure Clinic 3
PROBLEM 5
PURPOSE 5
THE HEART FAILURE PATIENT 6
CONCEPTUAL FRAMEWORK 9
LITERATURE REVIEW 12
Heart Failure Disease Management and Nurse Practitioners 13
Risk Factors Modification and Heart Disease 15

Education and Behavior Modification of Risk Factors Associated with Heart Disease IS

PROJECT DEVELOPMENT 17
IMPLICATIONS FOR APN PRACTICE 19
IMPLICATIONS FOR RESEARCH 20
IMPLICATIONS FOR EDUCATION 2]
CONCLUSION I 21
REFERENCE LIST 23
APPENDICES
Appendix I 29
Appendix 2 30
Appendix 3 31
Appendix 4 32

LIST OF TABLES
Table I : Percent of Population by Age Group 1993 ........................................ 3
Table 2: Tri-county Area Population Growth 1993-1997 .................................. 3
Table 3: Risk Factors and Suggestive Symptoms for Heart Failure ....................... 7
Table 4: Orem’s System Contrasted with NYHA Classification System ................. I I

LIST OF FIGURES

Figure I: Orem‘s Self-Care Model ........................................................ 8

INTRODUCTION

Heart failure results when the metabolic demands of the body are unable to be met
by the cardiac output. The incidence of heart failure is rapidly increasing and becoming a
common diagnosis in patients over the age of 65 (Boynton, 1989). Each year 500,000
new cases of heart failure are diagnosed (Yacone-Morton, 1995; Deedwania, I994). The
prevalence of heart failure is increasing while that of coronary heart disease, stroke, and
myocardial infarction is decreasing (Deedwania, 1994). Heart failure is thought to be the
number one reason for hospitalizations among the elderly (Ghali, Cooper & Ford, 1990).
The increased incidence and mortality of heart failure has led to many health care dollars
being spent in admissions and readmissions for exacerbation of the disease and long term
care of these patients (Brass-Mynderse, I996). The purpose of this project is to develop a
product to improve the care of patients with heart failure.

Heart failure is a progressive and lethal disease with serious socioeconomic
implications. Although the prognosis of heart failure is variable dependent on
complications and comorbid conditions, current estimates suggest that fewer than 50% of
those diagnosed with heart failure will survive 5 years (Rector & Cohn, I995). The
Framingham study showed a cumulative mortality rate of approximately 75% nine years
after the onset of clinical symptoms (McKee, Castelli & McNamara, 1971). Hospital
admissions related to heart failure have increased dramatically in the last 20 years. Heart

failure is now the leading DRG (Diagnosis Related Group) in the Medicare program that

 

 

 

 

.llIl l'llllllltl lull

provides care for most Older Americans (Cuffe, Rao & O’Connor, 1997; HCFA, I994,
Ghali, Cooper & Ford, I990).

Heart failure is a devastating diagnosis with no cure at this time. Heart failure
occurs when the heart is damaged from either disease or ischemia caused by heart attack.
If the heart weakens due to disease or damage, pumping of blood becomes ineffective,
leading to heart failure. There are two types of heart failure. Left-sided failure causes
blood to back up into the lungs, causing extreme shortness of breath. Right-sided failure
causes a back up of blood in the peripheral system and is evidenced by fluid accumulations
in the lungs, liver and ankles. Heart failure patients become increasingly less fimctional in
their daily lives and are prone to frequent hospitalizations. The realistic goals for heart
failure patients are to prevent the exacerbation of the illness, and to decrease the frequent
hospitalizations that go along with this disease.

Three possible causes identified for the increased incidence of heart failure are (I)
decreased mortality from acute myocardial infarctions, (2) better management of
hypertension, and (3) the ever increasing life span of the population (English & Mastrean,
I995). The last of these, the aging of the American population, is identified as the single
most important reason for the rapid rise in this disease. The American Heart Association
estimates yearly cardiovascular expenses at 117.4 billion, this figure includes the costs of
physician and nursing services, hospital and nursing home services, medications, and
productivity lost from disability (American Heart Association, 1993). The expense
involved in caring for patients with this chronic illness indicates a need for primary care

interventions associated with the diagnosis of heart failure.

Local Trends

The aging population continues to soar in Michigan and the tri-county areas of
Ingham, Eaton, and Clinton counties. In the Tri-county area the over age 55 population is
growing at twice the rate as the under age 55 population. The fastest growing segment of
the population is those over age 85 (see tables 1 and 2).

Table l - Percent of Population by Age Group 1993

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Age Group TrI-(fomty Michigan United States
- 55 84.1% 79.6% 79.1%
55-74 11.8% 15.2% 15.40.
75+ 4.1% 5.1% 5.50.

Table 2 - Tri County Area Population Growth 1993-1997
Age Group 1993 1997 Percent (Ii-mm:
.7 55 372.026 383.911 3.20.
55-74 52.149 54.085 3.7%
75-84 13.212 14.996 13.5%
85 . 4.887 6.247 27.8%
TOTAL 55 1 70.248 75.328 7.20.

 

 

 

 

 

 

Local Cardiovascular Health Statusafnd The Need for A Heart F flure Clinic

 

Risk factors for cardiovascular diseases include high blood cholesterol levels,
which rise with age up to age 60, and high blood pressure which increase throughout life
(Messerli, 1993). The Tri-County Office of the American Heart Association office has
reported that nearly 80% of residents are at risk for heart disease, and that cardiovascular

disease was one of the major causes of death in 1993, with 41% or I 161 deaths attributed

 

to heart disease (Lansing State Journal, 1996). Additional risk factors are sedentary life
styles and smoking.

The combination of an upward trend in the aging population, and the decrease in
cardiovascular health of tri-county area residents has resulted in increasingly more health
care dollars being spent for long term care. A review of available resources in this area
Shows that a heart failure clinic would be unique to this community. Cardiac rehabilitation
programs are available in the tri-county area at Ingham Regional Medical Center, Sparrow
HoSpital, Clinton Memorial Hospital and Lansing Community College. There is only one
program in the area dealing directly with the management of heart failure that is associated
with a particular cardiology practice and is not open to the general public. In the tri-
county area, heart failure patients must go to a physician’s office or an emergency room
for care. Home care agencies are an additional source of care for heart failure patients, but
are limited to the period of time that the patient is homebound.

With the advancement of heart failure, patients progress to experience alterations
in physical and functional abilities. Functional status can be affected by non-compliance
with medications, diet and fluid restrictions, and lack of exercise. Participation in a
program focused on this disease process can improve patient compliance. Education and
scrupulous monitoring of heart failure patients has been identified as the number one way
to help reduce the costs associated with the management of this disease (Dracup, et.al,
1994). Heart failUre clinics are an effective way of managing this chronic illness
(Cardiology Preeminence Roundtable, 1994).

Elderly heart failure patients are at increased risk for early re-hospitalization three

to six months after initial discharge, with readmission rates ranging from 29 to 47 percent

(Rich et al, 1995). Heart failure clinics can decrease the number of early readmission by
addressing clients behavioral factors that fiequently contribute to readmissions.
Problem

Education and close monitoring has been found to be the best way to help heart
failure patients maintain quality of life and decrease the frequency of hospitalizations
associated with this disease (Rich, et al, 1995; Dracup et al, 1994). Primary care visits are
ofien short in duration, and do not allow much time for education. The heart failure clinic
is a way to effectively assess patient status and to provide structured education. There is
presently no tracking tool to monitor patients admitted to the clinic, including their health
status, and educational needs. In order to have easily accessible records, a database is
needed.

Purpose

The purpose of this Scholarly Project is to develop a database for use in the heart
failure clinic to be an overall tracking tool for the clinic. Having all clinic patient
information in a database will allow the APN to quickly identify trends related to changes
in patient condition and monitoring of educational records. This database will also have
the potential to serve as a resource for future research projects related to heart failure.

An additional benefit of having computer based patient records (CPRs) is the ease
in monitoring effectiveness of care and the measurement of outcomes. CPRs are defined as
“a complete and accurate patient health record residing in electronic format within a
system that is specifically designed to support the entry, management, and extraction of
the patient health record by caregivers and other users duly authorized with a valid need

for the information” (Brooke, 1996). The technological advancements of information

systems have increased the need for hospitals, physician’s offices, clinics, insurances and
billing companies to use CPRs. CPRs improve emciency by allowing quick and easy
access to files and patient information. Costs improvements will be seen as staff time is
saved through decreased time spent on data entry and retrieval, and further reduces
paperwork and eliminates the duplicate storage of data (Lange, 1997).

The Hg Failure Patient

The first signs patients are in heart failure are usually increased shortness of breath,
fatigue, and exercise intolerance. Advancement of heart failure results in a decreased
quality of life, as fimctional capacity is lost due to the increase in symptoms. Quality of life
includes physical and psychological firnctioning, work and social role performance, and life
satisfaction, and is often afl‘ected by personal perception of health.

Heart failure can often be misdiagnosed as chronic obstructive pulmonary disease
or vice versa. Heart failure needs to be appropriately diagnosed and then treated. Left
untreated, heart failure is a fatal disease. Patients and significant others must be able to
identify symptoms that lead to decline in firnctional ability and often leads to a hospital
admission. The risk factors associated with heart failure and symptoms that are suggestive
of heart failure are shown in Table 3. Heart failure is given a severity level based on
exercise tolerance and symptoms. The most commonly used scale is the New York Heart
Association (NYHA) Functional Classification Scale (Gorlin & Learnan, 1989). A chart of
the NYHA Classification Scale is shown in Appendix 1.

The classification level at which heart failure is first diagnosed can afl‘ect the
patient’s perceptions of the disease, and how they feel about modifying their behavior. The

education of heart failure patients needs to include information about disease progression,

medications, symptoms, and symptom management. Patients who are knowledgeable

about their disease have fewer hospitalizations, better quality of life, and a longer

prognosis (Dracup, Baker, Dunbar, Dacey, Brooks, Johnson, Oken, & Massie, 1994).

Table 3 Risk Factors and Suggestive Symptoms for Heart Failure

 

 

Risk Factors:

Older age

Systemic hypertension

Isolated systolic hypertension

Coronary heart disease

Diabetes mellitus

Obesity

Reduced or falling vital capacity

Cigarette smoking

Hematocrit level

ECG abnormalities
(Deedwania, 1994)

 

Symptoms:

Paroxysmal nocturnal dyspnea
Orthopnea

Dyspnea on exertion

Decreased exercise tolerance
Unexplained confusion, altered
mental status, or fatigue in an elderly
patient

Abdominal symptoms such as nausea
or abdominal pain associated with
ascites and/or hepatic engorgement

(AHCPR, 1994)

 

Heart failure risk factors that are modifiable are hypertension, obesity, smoking,

and hyperlipidemia (English & Mastrean, 1995). The same authors also identified “heart-

smart” behaviors that can be used as primary prevention of heart failure as low-fat, low—

cholesterol diets, regular physical activity, weight reduction and smoking cessation. The

success of maintaining changes in any of these modifiable behaviors is greatly increased

with education and support.

The standard of practice in primary care, in the treatment of heart failure is the

AHCPR Clinical Practice Guidelines. AHCPR guidelines are developed by a

multidisciplinary panel and are based on research. Treatment for heart failure is based on

 

 

the severity of the disease. In the asymptomatic patient, treatment centers on the
prevention of symptoms. When the disease becomes more advanced, treatment is geared
toward the control of symptoms and decreased exacerbations. This is achieved by
assessment and monitoring, pharmacological management and most importantly with
patient and family education and counseling. Education is the piece that must be there to

improve patient compliance with treatment protocol.

113 CONCEPTUAL FRAMEWORK
The conceptual framework chosen to guide this project is Dorothea Orem’s

Theory of Self Care Deficit that describes when nursing intervention is required
(Hardweg, I991; Fawcett, 1995). Nursing interventions are necessary when the patient is
experiencing a deficit in self-care. Interventions for heart failure patients must include
patient education during all stages of the disease, but it is most beneficial during the period
when this chronic illness is first diagnosed. Orem identifies the five methods used by
nursing to assist with health care as:

Acting for or doing for another

Guiding another

Supporting another (physically or psychologically)

Providing an environment promoting personal development in relation to

becoming able to meet present or future demands for action
5. Teaching another

.43.“.NT"

Figure I is a model of Orem’s Self-Care theory.

 

 

Patient
Self-Care
Capabilities Therapeutic
(Self-care Sell-care
Agency) (- Deficit relationship Demand
Nurse
Nursrng
Capabilities
Fi re 1 Orem’s (Num'ng
an Agency)

Self-Care Model (Hardweg, 1991)

10

Six basic concepts represented in figure I represent the conceptual structure of the Self-
Care Deficit Theory of Nursing.
0 Self-Care is a learned behavior or deliberate actions individuals initiate and perform on
their own behalf in maintaining life, health and well-being (Orem, 1991).

o Self-Care Agency is the ability a person has to engage in self-care. Self care agency
develops in childhood, matures in adulthood, and decreases with aging.
0 Therapeutic Self-Care Demands can be identified as those requirements that
individuals perform to maintain life, health and well being. Therapeutic self-care demands
include: maintaining sufficient intake of air, water and food; maintaining balance between
activity and rest, and solitude and social interaction; the prevention of hazards to human
life, functioning and well-being; the provision of care associated with the processes of
elimination and excrement, and the promotion of the development of a ‘normal’ self
concept
0 Nursing Agency is a specialized acquired ability of adults to engage in deliberate action
that is learned and performed with a goal in mind and is exercised for the well-being of
others
0 Self-Care Deficit is an unequal relationship between the capabilities for self-care and
the individual’s therapeutic self-care demands.
0 Nursing System includes all of the actions and interactions that take place between a
nurse and a patient in nursing practice situations.

An activated nursing agency produces diagnosis, prescription, and regulation of
self-care, for persons with self-care deficits associated with their health state. The nurse

must be able to identify the self-care deficit and the individual client needs followed by an

ll

intervention that assists the client in overcoming this deficit. Using Orem’s theory in the
heart failure clinic setting, nurses would work with patients guiding them through the
disease process by educating them about heart failure, and supporting them as they learn
to make lifestyle changes for the purpose of increased self-care capabilities.

Orem classifies three nursing systems utilized in assisting patients with self-care: the
wholly compensatory system, the partly compensatory system, and the supportive-
educative system. It is when the patient’s disease state is advanced that they would be in
the wholly compensatory state and would require the most nursing intervention with the
activities of daily living (ADLS) and the activities of independent daily living (AIDLs). In
the partly compensatory system, the patients would be able to do some of their own care,
but when becoming symptomatic with exertion would require some assistance with care.

The NP would work with patients in the educative-supportive system in the early
stages of heart disease. As patients progress through the levels of heart failure, it is likely
that a nurse would work with them through all of the levels. While working in the
supportive educative system the advanced practice nurse will be able to positively impact
the heart disease process by assisting in the delay progression of the disease, thus
improving patient’s quality of life. It is also at this level that it might be difficult to get the
patient involved in self-care activities. If individuals are not actively experiencing
symptoms, they are less likely to believe that they have a chronic illness and may be less
receptive to behavior modification interventions. Patients might also move between the
partly compensatory and the wholly compensatory systems when they are experiencing

acute exacerbations of the disease.

mi

12

Table 4 contrasts Orem’s systems with the New York Heart Associations Classifications

of severity of heart failure.

Table 4 Orem’s System Contrasted With N YHA Classification System

 

System

NYHA Classification

 

Wholly Compensatory System

Nurse actions

- Accomplishes patient‘s therapeutic self-care

- Compensatcs for patient‘s inability to engage in
self-care

- Supports and protects patients

Patient actions

- Accomplishes therapeutic self care

NYHA Level IV
Severe limitations
Symptoms present even at rest

 

Partly Compensatory System

Nurse action

-Performs some self-care measures for patient
-Compcnsates for self-care limitations of patient
- Assists patient as required

- Regulates self—care agency

Patient action

-Pcrforms some self-care measures

-Regulates self-care agency

-Accepts care and assistance from nurse

NYHA Levels II and III

Level III

Moderate limitations

Symptoms noted with minimal activity
Level II

Slight limitations

Symptoms during ordinary daily activity

 

 

Supportive-Educative System

Nurse action

-Regulatcs the exercise and development of self-care
agency

Patient action

Accomplishes sel f -care

 

N YHA Level I
No limitation
Asymptomatic during usual daily activities

 

‘1‘”

LITERATURE REVIEW

The literature search conducted for this study provided a wealth of information
related to the heart failure disease process and medical management of this chronic illness.
There is also much information about the physiological manifestations and risk factors
associated with heart failure. For the purposes of this project, the literature review will
focus on the benefits of heart failure clinics to patient quality of life and the benefits of
education on heart failure.
flaart_Failure DISleC Maaagementfiamd Nurse chtitioners

Feldman, Venture, & Crosby, (1987) identified a number of studies that looked at
effectiveness and value of nurse practitioners in the management of chronic disease. Brass-
Mynderse (1996) found that disease management for heart failure at a California based
nurse managed clinic, estimated the potential savings of more than $2.5 million in lost
revenue by managing this chronic disease and keeping patients out of the hospital. The use
of nurse practitioners in practice and in chronic disease management is still not fiilly
accepted by the medical community. A 1995 Cardiology Preeminence Roundtable Study
pointed out that the concept of heart failure clinics is still revolving and controversial, and
is often seen by cardiologists and primary care physicians as a threat to their business or an
infringement on their provider patient relationship.

Risk Finns Modification and Heart Diseas_e

The benefits of modifying risk factors related to heart disease have been shown in a

number of studies. Those risk factors that are modifiable and have the most effects on the

cardiovascular system are exercise, hyperlipidemia, hypertension, and smoking.

13

14

DeBusk (1996) looked at why he believes the present health care system is often
unsuccessfirl with risk factor modification. He writes that this is because physicians most
Often have brief outpatient encounters with patients, and that physicians feel that they
often get little nonphysician support from nurses in primary care. He further identified that
physicians often give risk modification a low priority, preferring to attend to acute
problems, and reimbursement for risk modifying behaviors are much lower in primary care
as opposed to the acute care setting.

The benefits of lowering lipids on cardiovascular disease were reported in several
studies (Consensus Conference, 1985; Holmes, 1., 1990; Pearson & Swan, I996).
Gaziano and Manson, (1996) studied the role fat, alcohol and antioxidants have on heart
disease and reported that there seems to be overwhelming evidence indicating that the diet
habits of the western culture plays a major role in artherosclosis, which in turn damages
the heart. Other diet considerations are the decreasing the amount of sodium in the diet
and careful monitoring of the amounts of fluid intake, both of which can worsen heart
failure symptoms (Dracup, et al, 1994).

Exercise has always been an important component of cardiac rehabilitation.
Fletcher, (1996) reported on the importance of developing a prescription for exercise for
cardiovascular patients. Exercise has been proven to have positive effects on left
ventricular firnction in studies by Fletcher, Oberrnan & Nanda, (1995), and Ghilarducci,
Holly and Amsterdam, (1989).

Smoking is another risk factor that is modifiable and has been proven to have
negative effects on the cardiovascular system. Many researchers have looked at the

effects of smoking on the heart and the positive effects of smoking cessation (Aberg,

15

Bergstrand & Johnson, 1983; Barry, Mead & Nabel, 1989; Cavender, Rogers & Fischer,
1992; Daly, Mulcahy & Graham, 1983). Rigotti and Pasternak (1996) report that
smoking is the number one preventable cause of death in the United States and an
important cause of coronary heart disease. This article identifies the unfavorable effects of
smoking on the heart as: a) acute increases in blood pressure and coronary vascular
resistance; b) reduction in oxygen delivery; c) enhancement of platelet aggregation; d)
increased fibrinogen; and e) depression of HDL cholesterol. Smoking cessation rapidly
reduces cardiovascular morbidity and mortality. The authors also point out that primary
care is the place where counseling about smoking cessation belongs.

The MULTIFIT study was a randomized clinical trail that examined a system
designed for coronary risk factor modification related to the behaviors of diet, for the
purpose of lowering blood cholesterol, exercise, and smoking in post myocardial infarction
patients. Nurse case managers followed patients in the study after discharge from the
hospital in three ways: 1) nurse-initiated phone contacts; 2) Computer generated patient
progress reports developed from questionnaires patients mailed in; 3) A total of 4 visits to
the clinic for baseline assessments and counseling. The MULTIFIT study proved to be
more effective in modifying these risk behaviors than follow up appointments as used in
primary care. This was attributed to frequent contact and support provided the patients via
telephone. The MULTIFIT study was so successfiil with risk factor modification that it
was expanded to include patients with diagnosis of heart failure, diabetes mellitus, and

hypertension.

l6

Educartion Ed Behavior Modification of Risk Factors Associated with Heart Failure

 

 

Beyond Heart Disease is a successfirl community program designed by nurses to
reduce long-term risk factors and risk of coronary events (Lipon and Carlson, 1994). This
six-week program focused on the education and Skill building techniques to assist clients
in modifying cardiovascular risk factors. Understanding that simply providing patients with
information about risk factors is not enough to cause change, the authors enlisted
Bandura’s social learning theory and created a supportive learning environment, conducive
for change. This program was followed up by telephone support to participants, which
further supported the patient’s efforts to change.

A study reported in the New England Journal of Medicine looked at the effects of
a nurse directed, multidisciplinary intervention for high risk patients aged 70 years and
older who were hospitalized with heart failure (Rich, Beckham, Wittenberg, Leven,
Freedland, & Carney, 1995). The basis of this study was to work with patients on
behavior modifications to see if it would affect 90-day hospital readmission rates, improve
quality of life, and decrease the costs of care for patients with heart failure. This study
concluded that patients did benefit with improved quality of life fi'om baseline, as
evidenced by a decline in the number of hospital admissions by 56.2 percent in the
treatment group, as well as an overall decrease in the cost of care by $460 per patient.

The Cardiology Preeminence Roundtable (1994,1995) presented a series of studies
looking at heart failure management, heart failure patient cardiac rehabilitation, and heart
failure clinics. The 1994 study tracked the cardiac rehabilitation of inpatients and
outpatients. Of importance in this study is the observation that the amount of education,

and patient interaction with staff directly correlated with decreased number of

I7

readmissions to the emergency room for heart failure related events. As a follow up, the
1995 study looked at the development and organization of congestive heart failure clinics.
The executive summary points out that heart failure clinics “have evolved as a source of
care which is specifically tailored to meet the needs of this unique patient population and
designed to compensate for the inadequacies of traditional methods of care.” The tracking
of outcomes is also noted to be an essential component of heart failure clinics.

Education is identified in many journals as an essential component of care for all
heart failure patients. (Seager, 1995; AHCPR, 1994). The chronic nature of heart failure
makes it important that patients understand not only the disease process but as well their
role in the management of the disease. Education and continuous reinforcement of self-
care management Strategies are vital in helping heart failure patients improve or maintain
their quality of life and delay the progression of heart failure (English & Mastrean, I995;
AHCPR, I994). Counseling and education were found to be crucial in assisting patients in
making major lifestyle adjustments leading to improved patient outcomes and decreased
unnecessary hospitalizations (Dracyup, et al., 1994; Brass-Mynderse, 1996).

It is of interest to note that a number of articles deal with the disease process of
heart failure and identify risk factors that are modifiable (Kannell & Belanger, I991;
Deedwania, 1995; Gorlin & Leaman, 1989; Young, 1995). The studies fall short by
completely leaving patients out of the picture, dealing only with diagnosis, medical
interventions and medications. Medical interventions and medications are much more
effective when coupled with education and counseling. If patients know what to expect of
the disease and the interventions, they are more likely to comply with the

recommendations for care.

PROJECT DEVELOPMENT

For this scholarly project, this author developed a database using Microsoft (MS)
Office. The main database is in MS Access with links to MS Word and MS Excel, for use
in a heart failure clinic. The parts of the database are:
I demographic and medical information - a table to track basic information about the
patient and store pertinent medical information
' patient medications - a table to keep a running record of medications. This table
includes medication names, dosages and dates the medications are started or stopped
' clinic visits —- a table to track assessment data collected during clinic visits
' telephone contacts — a table to keep track of information gathered during a telephone
contact with a patient
I Primary care physicians and cardiologists - tables that store lists of frequently used
physicians that will be contacted periodically for updates on the patient's progress
Supplementing the database, links to MS Word are used to generate copies of
records and form letters used to communicate between the clinic and client’s primary care
physician. MS Excel is used to score and store results on The Minnesota Living with
Heart Failure Questionnaire (Rector and Cohn 1992, cf, Appendix 2). This survey is
given to patients as they enter the program, and then at 3, 6, and 12 months after
completion of the clinic program
When patients are admitted into the clinic an initial record is started in the database
including demographic and pertinent medical information about them (Appendix 3). The
patients are assigned a number, which is used as a reference link to all other tables in the
database. Clinic visits are monitored in another table that tracks current patient assessment
and medication data and records what education has been done for that patient (Appendix

4). Additional tables in use with the database are medication records, and telephone

contact forms that are integrated with the patient’s initial record. Reports will be computer

’3

l9

generated drawing information from all of the forms to provide accurate and up to date
information. Reports can be used as motivation for the patients by showing them their
progress or areas that still need work. Generated reports will also be used to communicate
patient progress to their primary care provider.

Confidentiality

Confidentiality between a patient and their medical care provider has always been
of utmost importance in the development and maintenance of therapeutic relationships.
The terms privacy, confidentiality and security are sometimes used interchangeably, but,
although they are related, they do in fact have different meanings. Styffe, (I997) identifies
these terms in relationship to information systems as:

o Prir-Iacy - the right of individuals to determine when, how, and to what
extent information is transmitted.

0 Confidentiality - trust placed that information shared will be respected
and used for the purpose disclosed.

0 Security - the protection of information from accidental or intentional
access by unauthorized people, including the modification or
destruction of the information.

The medical record keeping business has been forced to advance into the
“computer era” as we have moved into what is known as the “information age”. With any
medical database comes the concern that patient records could get into the wrong hands.
A patient needs to feel safe in revealing all significant medical information to their
provider. Breach of confidentiality is a legitimate concern when patient records are stored

electronically. Patient privacy is an issue of utmost importance as more and more patient

records are computerized. The lack of security of patient information can cause the loss of

U"

20

medical and or life insurance and the ability of a person to Obtain coverage of any kind.
Once a person has been labeled with a medical disability, the label can follow them for life.

The best way to have a secure system is by limiting access to that system. This
database for the time being will be on a stand alone computer system dedicated for use
with this clinic. A password will be required to get into the system and only the patient’s
contact number is accessible when looking at individual visits and for data queries. This
helps to ensure patient confidentiality in this database. MS Access has the ability to
encrypt stored data, thereby further increasing security.

Evaluation

Tracking patient data and interventions with a computerized database simplifies the
task of evaluation. Patient care interventions need to be evaluated for effectiveness, and
encounters with the patients need to be evaluated for quality, process of care and
outcomes of care.

The effectiveness of interventions will be evidenced by patient’s response to
therapy and is seen as outcomes of care. Outcome variables are these measures that
indicate the patient’s disease state. Other measures of effectiveness are frequency of
emergency room visits, hospitalizations, and exacerbation of the disease. This program
also tracks baseline and periodic scores of the Minnesota Living With Heart Failure
Questionnaire seen in Appendix 2. This questionnaire looks at the patient’s quality of life
and will be an indicator of effectiveness of interventions.

Evaluation of the delivery of care looks at process variables involving the use of
protocols for patient contacts and follow up. Questions to be addressed are:

' Were patient contacts done according to protocol?

2|

' Were patient intervention protocols followed?

' Did follow up communication with primary care providers occur according to

protocol?

Evaluation of quality of care can often best be determined by tracking patient
satisfaction. Patients tend to base the quality of the care they receive on the encounters
they have with the care providers. If the environment is deemed therapeutic by the
patients, patient satisfaction will go up. The database has the potential to generate patient
satisfaction surveys, although this will not been dealt with at this time.

Implications for NP PLactice

A heart failure clinic is an innovative addition to primary care for patients with a
chronic illness. The expert training and assessment skills of nurse practitioners (NP) make
them the ideal care providers for quality compassionate cost effective care to heart failure
patients in a primary care setting. Participation in a heart failure clinic will help patients
maintain much of their health and independence for as long as possible. An additional
benefit to the health care system is cost savings recognized because the NP will help the
patient stay out of the acute care system.

NPS working in a clinic setting will have the opportunity to utilize many skills and
roles in dealing with clients and their families, by helping them to understand what the
disease is, how it will progress, and what behavior modifying interventions can be done to
lessen the severity of the disease, and maintain functional Status. Educating patients in the
need for strict adherence to dietary and drug regimens is identified as an essential element

in cost effective management strategies for heart failure (Seager, 1995). Client visits

22

include regular assessments of current health status, and the opportunity for the NP to
provide counseling with the clients and their significant others.

Nurse managed clinics also provide NPS the opportunity to work in collaboration
and consultation with primary care physicians and cardiologists as they work with clients.
Collegiality is built as NPS communicate with physicians on their patients involvement
(Sherman, 1995). This database will benefit the client, by allowing the NP to increase
continuity of care, enhance patient capacity for self-care via appropriate teaching and to
individualize treatment plans by following the patient’s progress and by looking at trends.
Implications for Research

An important component of this database is the ability to query data, and the
tracking of outcomes that can be used for firture research. Evidenced-based practice is
important for health care providers in developing treatment protocols that should lead to
improved patient outcomes. Many of the treatment guidelines in use today come fi'om
research that was done in the past. An example of this is the AHCPR guidelines (1994),
that were developed collaboratively after evaluating the research available on specific
subjects.

This database has the ability to track many aspects related to the patient and
patient care provided. There are a number of research questions that could be answered by
tracking patient information in a database. Some examples of research questions are:

' The identification of risk factors in the local area

' Risk factor modifications affected by participation in a heart failure clinic

- The effect on quality of life with participation in the heart failure clinic

23

' The financial benefit seen by decrease in hospitalization and emergency room

visits.

Impligations for Edumon

Patient education has been determined to be one of the most important ways to
help patients manage chronic disease. Educating patients can increase their cooperation
with data collection leading to increased quality of their own care, and can improve the
knowledge upon which future care will be based. This database will assist the APN in
tracking the education done with individual patients. Using the database to monitor trends
and changes in patient condition will help the APN determine the results of the education
done.

In addition to patient education, there is a need for APN educational programs to
provide instruction in the evaluation and role of computerized databases and their ability
to enhance the quality of patient care.

CONCLUSION

This is an era of advanced information technology necessitating that medical
records are up to date and efficient. The use of computerized patient care records for
heart failure will improve the efficiency of the clinic and allow for more individualized care
of the clients. This database is designed to assist NPS with keeping accurate patient care
records in a time saving manner.

As managed care becomes more a part of patient care delivery, the tracking and
reporting of outcomes become more important. This database will allow easy assess to

data and a means of tracking and reporting patient care outcomes.

24

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29

Emma;

NEW YORK HEART ASSOCIATION
HEART FAILURE CLASSIFICATION
v CLASS I No limitations on physical activities

v CLASS II Slight Ilmltatlons on physlcal activity. NO
symptoms at rest

v CLASS 111 More severe limitations. Usually comfortable at
rest. Symptoms with many physical activities.

v CLASS IV Cannot carry on any activities without symptoms.
Symptoms present at rest. ,

30

 

 

N0 Little

Very

Very
Much

 

Did your heart failure prevent you from living as you
wanted in the past month by:

1.Causing swelling in your ankles, legs, etc.?
2.making your working around the house or yard
difficult?

3.making your relating to or doing things with your
friends or family difficult?

4.making you sit or lie down to rest during the day?
5.making you tired, fatigued or low on energy?
6.making your working to earn a living difficult?
7.making your walking about or climbing stairs
difficult? -

8.making you short of breath?

9.making your sleeping well at night difficult?
10.making you eat less of the foods you like?
11.making your going places away from home
difficult?

12.making your sexual activities difficult?
13.making you recreational pastimes, sports or
hobbies difficult?

14.making it difficult for you to concentrate or
remember things?

15.giving you side effects from medications?
16.making you wony?

17.making you feel depressed?

18.eosting you money for medical care?
19.making you feel a loss of self-control in your life?
20.making you stay in the hospital?

21 .making you feel you a burden to your family or
friends?

From Patient‘s Self-Assessment of Their Congestive Heart Failure
Part 2: Content, Reliability and Validity of a New Measure,
The Minnaota Living with Heart Failure Questionnaire, (p206)

 

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31

Appendix 3

J Heart Failure Clinic 1
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